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<br />_ STATE OF NEERASKA-DEPARTMENT OF HEALTH
<br />BUREAU Of ViTAI STATISTICS
<br />CERTIFICATE OF DEATH ,, _ ~3-- tjU~4~
<br />- OEN -NAAFE NRS MIOOLE ~~~ lAii SE% ~OATE Of OEATN (Mp . Day. Yr )
<br />PEARL E:oLFiA 6SCKELSEN female j January 19, 1982
<br />_ ~2- a
<br />RACE iag.. Wbifo.REptt,Aw[i an ORIGIN(pESCENTf[.g.. UOlipn,MO.~son, AGE-Ivry e.- e~UNDER_I VEAAI UNDER( DAY DATE Of BIRTH (MO, DeY, Yr.)
<br />-Mdiow, i(Y) G[,rrlon. Nt )(Spocr(y) (Y•r) ~ MO$ DAYS HOURS MIN$
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<br />2E
<br />s AmerlCan lep 72 !ab __ Ia< _ , Nov. 21, 1909
<br />AN TATE Oi BIRTN fN npr in U 3.A. CITI2FN Of WNAT COUNTpx MARRIED. NEVER MARRIED. NAME OF SPOUSE (I/.d., g.+o .noid[n rtpm[)
<br />wWY! ~ WIDOW ED. DIVORCED lSpNJy]
<br />HetaTan LIinnesota Iv L'.S.A. „D t:.arried ~„ diner ,.1ickelsen
<br />AL SECURITY NUMBER oSUAI OCCUPATION7Gi+e Sind p(We.E dpno during "or iKIND Of BUSINESS OR INDUSTRY ~COUNIY Of DEATN --
<br />508-32-2787 ,,~":Ye~.°~i~Ef3"'~osf'~al Clerk I;,SbU.S. Fost Off. ~IApDouglas
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<br />TOWN OR LOCATION Of DEATH INSIDE CITY IIMITS »OSPiTAL Op Ot MER IN$iITUTION-NOmo (I(nN.n [utN. III HOST O[INSr Ind~.a,o DOA,
<br />~($p[rr/y x[I Or NOI g,.. rlr and n.,mAe•) Ourp r.nr/fi... R,. Inpo,~.ul lfpRdy)
<br />Omaha _~„Ryes ~,.d GTlarkson Hospital .,,,p Inpatient
<br />7FNCE-STATE COUNix CITY,TOWN ORIOCAIION i$iREET AND NUMBER rINSIDF CITY UMITS
<br />Nebraska „B Hall ,k Urand Island ,Sd423 N. Custer Ave. ;s;"'~''~`g°rN°'
<br />E~-FiA~CbF-~~ MtODI IASI ~ MOIMER MAIDEN NAME i1R$T MIDOFE U T-
<br />Unk. Reynolds %17 ink.
<br />15 DECEASED EYER IN U S. ApMED fORCE57 ~ INFORAUNT-NAME- REfAtIONSHIP -MAILING ADDRESS (31[FFi O[ [ I D NO. Citt i , fiiiE. 211)
<br />a DI YN. a,,..p. pne dN., m ..,.n.. ~e g i' .
<br />no`s" ! ---- ,g iSiner tJickelsen,Hus 4211-N. Custer Ave.,Grand Island
<br />--- --- - -- - r-----
<br />1E,Cr[Iwption,Remo+otfDATE CEMETERY OR CREMATORY-NAME 'LOCATION CItt Op TOWN STATE
<br />Jan. 22'
<br />Burial I2ob 1982 ~2a Elmwood Cemetery t0d St. Paul, Nebraska
<br />U~{R-$tGNAfURE i EICENSE NO I FUNERAL MO~.SE -N~MF AND ADORE $S ~ s [FFF of I i D No. crrr OR FOWN. fiAFF. tlFl Yebr
<br />'/,f~j ~' f~u, 2~qA;.. Livinr,ston-Sonder^:ann's, 705 W, Koenig, Grand Island
<br /> .n...1,1.4Nd~ tnModpR dwrM e..upW e. t• •...• tlan en/y d.• ro ~t eon o d a o • and d n ro r ~r.uuvfu .ror.d 'en d•orF aturrM N
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<br />PR000UNCE00EAD (PRONOUNCED DEAD(MOOr)
<br />SS W1TE Of pEATN (Me., Opt, Yr.)
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<br />T - y I!d_ _ I21. M
<br />NAME AND ADORE OF CERTIFIER (r»YSICIAN, CORONER'S PHYSICIAN OR COU +TV %(]RNErI !irp• o• v, ~~i
<br />eerie, M.D 363 roct_ors_ AldQ.__Omaha, Ne. 68131
<br />RfGISTMR 'DALE RECEIVED BY REGISTRAR (MO, Day. Yr.)
<br />2N:F i- ,7_f~j~)~~ - ---- -. ~an_ J A -1 2 $ ~9oG
<br />ATf RUSE ( TfE DNFY ONF CAU$f R IN OR I ib! AND t.ll ner.pl E.I..« wIH RM dwM
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<br />~,, Pulmonary Embolism _ ____
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<br />W AS A GONSEOUENGF OF
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<br />Glioblastoma
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<br />OUE TO, Oi AS A CONSEQUENCE Oi.
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<br />_- - AGODtM. StNBR!_MOMICILNi. UNDFT. WlE Of IH]u[, ;M•- C ,. 'nOU[ p i,uu[F ~FSC[fEt nOw Iruu[r OCLU[R!O
<br />_ OR KNOING WYFS1WAilOF1 (SpNdy/
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<br />'--EN2LIR1 i Y,DRR ~.IACE OF fN]U[Y- Ar ba,, fora. w..,, foray -tOr •*ICn SF[FEt OE [ F D No C1tt Ot TOWN STAtE
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<br />W$BN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />STATE DEPARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />A TRUE COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DBPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />IS THfi LHGAL DHPOSITORY FOR VITAL REC)O~RD~S.
<br />~/~Lif~Q~ d"'l~.r rt..tJ
<br />DIRECTOR OF VTIAL STATISTICS AND ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA Issued February ~, 19II2
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